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Cardiotocography Monitoring Standard
Statewide Obstetric Support Unit on behalf of the System Manager (Patient Safety and Clinical Quality Directorate)
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1 Introduction 2
2 Background 2
3 Educational requirements 2
4 Clinical requirements 3
4.1 Fetal heart rate assessment 3
4.2 Uterine Activity Assessment 3
4.3 CTG monitoring in clinical practice 3
4.4 Cardiotocograph recording and reporting 4
4.4.1 Antenatal CTG 5
4.4.2 Intrapartum CTG 5
4.5 Clinical Care Escalation 6
5 Clinical audit and compliance 6
6 Definitions 7
References 8
Appendix A: Escalation Pathways 9
Appendix B: Example of standardised CTG reporting acronym 11
Appendix C: Audit Sheet for WA CTG Fetal Monitoring Standards 12
Appendix D: RANZCOG Clinical Audit Tool (example) Intrapartum CTG fetal monitoring 14
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1 Introduction
The aim of this mandatory Standard is to set out the minimum requirements for cardiotocography (CTG) monitoring. These minimum requirements are designed to improve perinatal outcomes and reduce the risk of adverse events related to the use of CTG monitoring in clinical practice in providers of maternity services.
Integral to contemporary maternity care is surveillance for evidence of both fetal wellbeing and early recognition of fetal compromise.
The focus of this standard is the use of CTG recordings of the fetal heart rate and uterine activity, hereafter referred to as CTG monitoring.
The primary purpose of CTG monitoring is to help identify signs of suspected fetal compromise in order to initiate management that may reduce or prevent fetal morbidity and mortality.
2 Background
The Cardiotocography (CTG) Monitoring Standard (the Standard) was developed in response to a directive by the Acting Director General of Health in 2015 to address inconsistencies identified in CTG monitoring clinical practices that may adversely impact perinatal outcomes.
The intent of the Standard is to provide a consistent framework for CTG monitoring to underpin clinical practice that is in accordance with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Intrapartum Fetal Surveillance Clinical Guideline Third Edition 2014 (https://www.ranzcog.edu.au/intrapartum-fetal-surveillance-clinical-guidelines.html) and relevant maternity service policies/guidelines. This Standard has been developed following consultation with key stakeholders in metropolitan and country maternity services
3 Educational requirements
Health Service Providers and Contracted Health Entities must ensure that all
clinicians with a responsibility for performing and/or interpreting CTGs meet the
following minimum mandatory education requirements:
o Confirmation of equivalent prior learning or an introduction to CTG monitoring,
content to be determined by the Health Service Provider or Contracted Health
Entity, prior to a clinician being required to perform or interpret CTG
monitoring.
o Completion of an annual CTG monitoring education update, content to be
determined by the Health Service Provider or Contracted Health Entity.
o Achievement of the practitioner assessment level commensurate with their
experience and level of responsibility in the delivery of maternity care,
assessed at annual review or at intervals determined by the Health Service
Provider or Contracted Health Entity.
o Completion of an advanced skill CTG education program which includes a
structured face to face learning component (e.g. FSEP face to face
multidisciplinary education session), content to be determined by the Health
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Service Provider or Contracted Health Entity, every three to five years,
dependent on the current level of required practice and responsibility for
performing and interpretation of CTG’s, as determined by the Health Service
Provider or Contracted Health Entity.
o Orientation to the Cardiotocography Monitoring Policy, this Standard; and any
associated relevant local maternity service guidelines and clinical escalation
pathways associated with CTG monitoring.
Regular, scheduled multidisciplinary learning opportunities should be provided to
promote effective communication, teamwork and conflict resolution between
clinicians with a responsibility for performing and/or interpreting CTGs.
4 Clinical requirements
4.1 Fetal heart rate assessment
While fetal heart rate detection may be performed using a Pinard horn or
stethoscope, it is a requirement that, whenever possible, clinicians will use an
electronic fetal heart rate detection device in order to provide an audible signal to
all present.
Electronic fetal heart rate assessment may be conducted in a number of ways:
o with a hand held device, used intermittently, in both the antenatal and
intrapartum period; or
o with a CTG recording device used:
periodically in the antenatal period; and
either intermittently or continuously in the intrapartum period.
4.2 Uterine Activity Assessment
It is important that the fetal heart rate and uterine activity are recorded
simultaneously.
This is critical for accurate interpretation of any fetal heart rate abnormality that may
occur.
Uterine activity is recorded electronically via a pressure sensitive toco-transducer
placed directly over the fundus, or by use of an intrauterine pressure gauge.
4.3 CTG monitoring in clinical practice
Women with recognised risk factors should be offered intrapartum CTG monitoring
as appropriate to their individual clinical circumstance
Women without risk factors should be offered routine assessment of fetal heart rate
using an electronic hand held device
Women should be given opportunity to make informed decisions regarding the use of
CTG monitoring
For women choosing a mode of fetal monitoring outside of current, best evidence-
based clinical guidelines:
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o Health Service Providers that provide maternity services must have an
agreed documentation standard. This must include a requirement for care
decisions outside of current, best evidence-based clinical guidelines to be
recorded clearly in the ante and/or intrapartum record.
o The senior medical officer responsible for care of the woman should be
made aware of the woman’s decision/s.
4.4 Cardiotocograph recording and reporting
When conducting CTG monitoring, the following CTG recording requirements must be met:
All staff members responsible for use of CTG equipment must be oriented to the
local equipment system/s, including clarification of the vertical fetal heart rate (FHR)
scale in use
Paper speed of 1cm per minute
Validated date and time settings at commencement of recording
Each CTG recording is labelled with the mother’s name, hospital number, date and
time of commencement
The indication/s for the CTG is/are annotated on the CTG recording
Any events that may affect the fetal heart rate are annotated on the CTG recording
Each Health Service Provider that provides maternity services must determine a
process for the management of CTG records which complies with their retention and
storage of confidential information requirements. This may include the use of an
electronic data retention system.
Definition of specific procedures should be considered for the long term storage of
paper-based CTG recordings, which fade over time, particularly for situations when
there has been a known adverse neonatal outcome.
Health Service Providers that provide maternity services must adopt a standardised approach to terminology, documentation and interpretation of CTG recordings to promote clear communication between clinicians. This will include the following requirements:
Written or verbal reporting must:
o include all features of the CTG;
o use a designated, structured description of CTG information, such as the DR
C BRAVADO acronym (Appendix B); and
o use standardised RANZCOG terminology,
Interpretation and response to findings must align with escalation thresholds and
processes described in Appendix A.
Interpretations, decisions and actions must be documented using a standardised
recording system as determined by the provider of maternity services. Examples
such as the Buddy System (NHS Saving Babies Lives, 2016) and Fresh Eyes
Approach (Fitzpatrick and Holt, 2008) are included in Appendix B.
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All CTG interpretations include the signature and designation of the reviewing
clinician/s
4.4.1 Antenatal CTG
As defined by Baker, Beaves and Wallace (2016) a normal antenatal CTG has:
o A baseline fetal heart rate (FHR) of between 110 and 160 bpm
o Baseline variability of 6-25 bpm
o A minimum of two accelerations within a 20 minute period (reactivity); and
o No decelerations.
While all CTGs require interpretation, those that DO NOT meet the above criteria are
abnormal and require IMMEDIATE FURTHER interpretation and management
based on the individual clinical situation and local care escalation pathways
Gestation should be taken into account when interpreting the significance of FHR
features which do not meet all the normal antenatal criteria
All antenatal CTG recordings must be reviewed in a timely manner by two clinicians
with responsibility for CTG interpretation (neither of whom are students) and prior to
the woman leaving the hospital.
4.4.2 Intrapartum CTG
In accordance with the definition in the RANZCOG Intrapartum Fetal Surveillance
Clinical Guideline – Third Edition 2014 a normal intrapartum CTG has:
o A baseline FHR between 110 and 160 bpm
o Baseline variability of 6-25 bpm
o No decelerations; and
o Accelerations
Baker, Beaves and Wallace (2016) note that although the presence of accelerations
in an intrapartum CTG is reassuring, their absence does not necessarily indicate
compromise.
For the purposes of this Standard, a CTG recording is not abnormal in the absence
of accelerations if all other features (normal baseline, normal variability and absence
of decelerations) are present.
Intrapartum CTG’s with abnormalities of baseline or baseline variability or where fetal
heart rate decelerations are present are abnormal and require IMMEDIATE ACTION
to review interpretation and management based on the individual clinical situation
and local care escalation pathways (See Appendix A).
Minimum requirements for intrapartum documentation of CTG interpretation by the
primary clinician should occur at 30 minutely intervals, unless more frequent
documented interpretation is clinically indicated
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Any interruptions of fetal heart rate monitoring including insertion of an epidural or
transfer to theatre, should be minimised and the fetal heart rate monitored and
documented regularly by intermittent auscultation
All intrapartum CTG traces must be reviewed by two clinicians, (neither of who are
students), at least 2 hourly or more frequently if concerned
4.5 Clinical Care Escalation
Health Service Providers that provide maternity services are required to have clear
escalation pathways specific to the local resources/situation, for:
o Abnormal antenatal CTG
o Abnormal intrapartum CTG; and
o Conflict of opinion between clinicians regarding the interpretation of, and/ or
management of, a CTG.
Any CTG classified as abnormal must be escalated according to the relevant local
escalation pathway as referred to above and managed in a clinically appropriate,
required time frame (See Appendix A)
The inability to record a quality CTG trace within 10 minutes of commencement, or
for any period of 10 minutes, requires escalation
Health Service Providers that provide maternity services must audit compliance with
adherence to clinical care escalation pathways, including scrutiny of reasons for non-
adherence.
5 Clinical audit
In addition to auditing compliance with this Standard using the audit tool provided in Appendix C (as required by the Cardiotocography Monitoring Policy), Health Service Providers that provide maternity services must:
Maintain a database capable of audit and reporting of individual clinician
compliance with the mandatory CTG education requirements of the Statewide
Cardiotocography Monitoring Standards.
Monitor clinical care compliance with the local requirements using a Clinical Audit
Tool (see Appendix D of the Cardiotocography Monitoring Standards as an
example).
An example: The RANZCOG audit tool - is provided in Appendix D.
Additional aspects of care recommended for clinical audit include:
Women with indications for continuous CTG who did not receive it
Delivery interventions arising from clinical interpretations of the CTG
Poor perinatal outcomes
Fetal blood sampling
Abnormal umbilical cord blood gas analysis.
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In addition to formal audits, it is recommended that Health Service Providers that provide maternity services discuss fetal monitoring and clinical outcomes at regular, scheduled multidisciplinary educational clinical practice review meetings. These meetings should involve review and interpretation of actual CTG recordings.
6 Definitions
Term Definition
Fetal Heart Rate Assessment Assessment of fetal heart rate that can be conducted in an intermittent and/or continuous manner, during the antepartum and intrapartum periods. Intermittent methods use a stethoscope, fetal stethoscope or Pinard horn, or Doppler ultrasound device. A cardiotocograph (CTG) is the only method of continuous fetal heart rate monitoring in common usage.
Escalation pathway A documented process that outlines actions required for timely review ensuring appropriate interventions for patients. This process will be site specific in relation to the local team structure and resources.
Pinard Horn A type of fetal stethoscope used to listen to the heart rate of a fetus during pregnancy. Also known as a fetoscope or Pinard.
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References
1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Intrapartum Fetal Surveillance Clinical Guideline - Third Edition (2014). Melbourne, Victoria: RANZCOG.
2. Department of Health, Western Australia. (2016). Clinical guidelines for Antepartum Fetal Heart Rate Monitoring. Perth, Western Australia: King Edward Memorial Hospital.
3. Baker LS, Beaves MC, Wallace EM. (2016) Assessing Fetal Wellbeing: A Practical Guide. Melbourne, Victoria: RANZCOG and Monash Health: 2016
4. National Health Service. Saving babies lives: A care bundle for reducing stillbirth. (online) 2016. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf
5. Fitzpatrick T, Holt L. (2008) A ‘buddy’ approach to CTG. Midwives 11(5): 40-1.
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Appendix A: Escalation Pathways
Interpretation and response to Antenatal CTG
Interpretation and response to Intrapartum CTG
Classification Baseline Accelerations Variability Decelerations Action plan
Normal Low probability of compromise
110-160 2 in 20 mins (Reactive)
6-25 bpm Absent Discuss with doctor and confirm follow-up arrangements as per clinical picture
Remove trace once all normal features are present
If 2 accelerations in 20 mins are not present after 1 hour, a further management plan is required
Abnormal
Any of these features
REQUIRES ACTION
<110 >160 Absent
(Non-Reactive)
3-5 bpm for > 45mins
<3 bpm
Present Notify doctor and midwife coordinator
Review clinical picture
Treat reversible causes
Arrange repeat CTG within 4 hours if clinical picture allows 2 x non-reactive requires an ultrasound for fetal wellbeing
Classification Baseline Variability Decelerations Action plan - intrapartum
Normal Low probability of compromise
110-160 6-25 bpm Absent Nil
Abnormal
Any of these features
In isolation unlikely to be associated with compromise
100-109 Early
Variable
Notify doctor and midwife coordinator
Continue CTG
Review clinical picture
Treat reversible causes
+/-Scalp stimulation or FBS
Review 30 minutes
Abnormal
Any of these features
REQUIRES ACTION
May be associated with compromise
>160
Rising baseline
3-5 bpm or >25 bpm for 30 minutes
Complicated variables
Late
Prolonged (below baseline > 90sec & <5 mins)
Notify doctor and midwife coordinator
Review clinical picture
Treat reversible causes
Scalp stimulation +/- FBS
VE to assess progress
Review management in light of above interventions – delivery may be indicated
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Legend for Appendix A: Interpretation and response to CTG
Normal continue as per plan
Abnormal requires review
Abnormal requires ACTION
Abnormal requires URGENT ACTION – Code Blue
Abnormal:
Any of these features
IMMEDIATE MANAGEMENT
Very likely to be associated with compromise
Bradycardia (<100 for > 5 mins)
<3 bpm
Sinusoidal
Notify doctor and midwife coordinator
As above: immediately
Consider tocolysis
Early assisted delivery
Reduce second stage or Category 1 (Urgent) C/S
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Appendix B: Example of standardised CTG reporting acronym
DR C BRAVADO acronym to assist with interpreting CTG’s is recommended
o DR - Determine Risk (indication for CTG)
o C – Contraction pattern
o Bra – Baseline Rate
o V – Variability
o A – Acceleration presence
o D – Deceleration pattern
o O – Overall classification and Outcomes agreed
Example of standardised recording system including requirement for review, interpretation and documentation signed by two staff
WA Country Health Service CTG Reporting Sticker
Appendix C: Audit Sheet for WA CTG Fetal Monitoring Standard
Standard requirements Maternity service process is compliant?
Yes/No
Minimum, mandatory education requirements for clinicians performing and/or interpreting CTG monitoring
include:
1. Confirmation of equivalent prior learning and/or an introduction to CTG monitoring prior to clinicians
being required to conduct and interpret antenatal and/or intrapartum CTG monitoring
2. Completion of an annual CTG monitoring education update.
3. Achievement of the appropriate practitioner assessment level commensurate with their experience
and level of responsibility in the delivery of maternity care.
4. Completion of an advanced skill CTG education program at intervals of between 3 and 5 years
5. Regular, scheduled multidisciplinary CTG review meetings
Orientation of all new clinicians with responsibility for performing and/or interpreting CTG recordings includes:
1. Minimum mandatory education requirements in the use of CTG monitoring
2. WA CTG Fetal Monitoring Mandatory and any associated relevant local maternity service guidelines.
3. Clinical escalation pathways associated with CTG monitoring
A documentation standard to record a woman’s choice of a mode of fetal monitoring outside of Health Service Provider clinical guidelines
Maternity service CTG recording standards include:
1. Paper speed 1cm/minute
2. Validation of date and time settings at commencement of recording
3. Recording is labelled with mother’s name, hospital number, date and time of commencement
4. Indication for CTG annotated on the CTG
5. Events that may affect the FHR are annotated on the CTG
Standard requirements Maternity service process is compliant?
Yes/No
CTG reporting: 1. RANZCOG terminology used for reporting CTG recordings 2. A designated structured description of CTG information
Requirement for timely review of antenatal CTG recordings by two clinicians
Minimum interval for CTG intrapartum CTG interpretation documentation is not more than 30 minutes
Second clinician review of intrapartum CTG recordings is required at intervals of 2 hours or less.
Care escalation pathway/s for management of abnormal antepartum CTG recordings
Care escalation pathway/s for management of abnormal intrapartum CTG recordings
Escalation pathway for conflict of opinion relating to CTG interpretation or management
A process for management of CTG records compliant with requirements for retention and storage of confidential information.
If applicable: procedures for long term storage of paper-based CTG recordings which fade over time.
A database capable of auditing clinician compliance with CTG monitoring mandatory education exists
Clinical audits completed:
1. Adherence to CTG escalation pathways
2. Clinical care practice (e.g. using the RANZCOG clinical audit tool)
Appendix D: RANZCOG Clinical Audit Tool (example) Intrapartum CTG fetal monitoring
Date: Patient ID:
1). What was/were the indications for CTG monitoring?
Yes No If yes specify:
Antenatal risk factors Yes No If yes specify:
Intrapartum risk factors Yes No If yes specify:
2). If the indication for CTG monitoring was not medical, who initiated the monitoring?
Dr Midwife Patient
3). Was admission CTG performed Yes No
If yes was the CTG Normal Abnormal
4). Was the use of a CTG in line with RANZCOG clinical practice guidelines?
Yes No
5). Was there clear documentation on the CTG of:
Patient name Yes No
Patient hospital number Yes No
6). Does the date and time on the CTG correlate with the date and times in the patients/client’s medical history (i.e.: are the date and time settings on the CTG machine correct?)
Yes No
7). Is the CTG generally of high quality?
With a well recorded fetal heart rate?
Yes No
With well recorded uterine activity?
Yes No
8). Was the CTG Normal Abnormal
9). If the CTG was abnormal
Did it influence management? Yes No
Did it influence/affect delivery? Yes No
10). In the patients history is a written/stamped report of the CTG?
Present Yes No
Appropriate/accurate Yes No
Signed Yes No
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© Department of Health 2017
Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.